| NPI | 1245397892 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: VA 0701003767) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VA 0710101831) |
| Enumeration Date | 2007-01-02 |
| Last Update Date | 2010-05-03 |